There was one study of a type 1 intervention, four of type 2 interventions, one of a type 3 intervention, none of a type 4 intervention, two of a type 5 intervention and eight of type 6 interventions. All of the studies included actions in the community, and all of the interventions that had activities aimed at improving health facilities also included training for service providers and, sometimes, other clinic staff.
The one study that examined a type 1 intervention was from Zambia (16); it reviewed baseline, start-up and end-of-study statistics on family planning and outpatient attendances by 15-24-year-olds in eight participating clinics and two control sites. In the intervention clinics, service providers were trained, and peer educators also received training to work in the community served by the clinic. Although there were increases in attendance during the study period, these were not significantly greater than the increases seen in control clinics during the same period.
The four studies of type 2 interventions were conducted in China (19), Rwanda (12), Uganda (17) and Zimbabwe (18). The findings from the Rwanda study were based on a cross-sectional survey that assessed the impact of exposure to the interventions on the use of services by young people (12); this was one of only three studies that explored the dose-response effect of interventions. There was weak evidence of increased use of services, most notably voluntary counselling and testing, by those with high exposure to the intervention compared with those with low exposure. The Uganda study used a quasi-experimental design with a non-equivalent control group and demonstrated statistically significant increases in service use as a result of the interventions (17). Although both these studies showed statistically significant differences in service utilization, aspects of the study designs were not clear, and they were therefore categorized as showing weak evidence of increased use of services.
The Zimbabwe study reviewed clinic data for a 1-year period following the implementation of the interventions, and was one of several studies that did not include any statistical tests but demonstrated that a service was provided and it was used (18). This was considered to be weak evidence of an increased use of services.
The study from China focused explicitly on increasing young people's use of contraceptives, particularly condoms, which were provided by a range of facilities. It was the only study included in the review that did not explicitly measure young people's use of services, but had condom use as the outcome variable (19). However, it was considered that condom use could be taken as a proxy indicator for service use in terms of how the study had been designed; there was moderate evidence for increased use from the quasi-experimental design that included a before and after component and also included a control site.
There was only one study that examined a type 3 intervention. This was from Brazil (20) and was designed to strengthen links and referrals among schools and health facilities. Although no statistical tests were carried out, the quasi-experimental evaluation showed weak evidence for no increased use of services related to the intervention.
Two studies looked at the effect of type 5 interventions: one from Zimbabwe (21) and the other from the United Republic of Tanzania (22). The intervention in Zimbabwe was primarily a media campaign that also provided training for service providers in designated clinics in the project area. The quasi-experimental design, which included a control site, showed statistically significant increases in self-reported health service-seeking behaviours that were associated with increased exposure to the intervention. However, there were no baseline data for these findings, and there was contamination of the control site. This study was therefore designated as providing weak evidence for an increased use of services, although in this study reported use of services, rather than actual use, was the outcome measured. The other type 5
study, from the United Republic of Tanzania, was one of two randomized controlled trials identified. The study did not show any statistically significant increase in service provision despite the implementation of health-worker training and interventions in communities and schools. It therefore provided moderate evidence for no increased use of services.
Type 6 interventions were the subject of the largest number of studies; these interventions include training for service providers and activities in facilities, as well as actions in the community and with other sectors. There were eight studies in the following countries: Bangladesh (26), Ghana (29), Madagascar (12), Mongolia (23), Mozambique (37), Nigeria (10), Senegal (25) and South Africa (24). As outlined in Table 6.4e, six of these studies showed weak evidence for an increased use of services. The randomized controlled trial from Nigeria (10) showed strong evidence of an increase in the use of health services; the study from Senegal (25), which used a before and after design and a control site, showed increases in service utilization, but these increases were not statistically different from those at the control sites.
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